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Medicine and Social Justice will have periodic postings of my comments on issues related to, well, Medicine, and Social Justice, and Medicine and Social Justice. It will also look at Health, Workforce, health systems, and some national and global priorities

Sunday, February 19, 2017

I recently saw the wonderful film “Hidden Figures”, which tells
the story of the African-American women who worked as “computers” (when the
word meant “people who do computations”) on the NASA program that sent men (and
later some women) into space. The focus was on three of the most significant of
these women, Katherine
Goble Johnson,Dorothy
Vaughan, and Mary
Jackson. Ms. Johnson (played by Taraji P. Henson) is a gifted mathematician
who calculated the trajectories of many of the early space flights (including,
as portrayed in the movie, John
Glenn’s orbital flight in February, 1962) and the later Apollo 11 moon
landing in July, 1969. Ms. Vaughan (played by Octavia Spencer) became an early
and leading computer programmer, a supervisor at NASA. Ms. Jackson (played by
Janelle Monáe) was the first African-American female engineer at NASA. All of
these women, and no doubt many others, were critical to the NASA space program.

All of them, as the film documents, were “firsts”. Among
many such firsts, Katherine Johnson (then Coleman) was one of the first
African-Americans and first African-American woman to desegregate the graduate
school of West Virginia University. Dorothy Vaughan was one of the first
programmers and first African-American woman supervisor at NASA. Mary Jackson
became NASA’s first African-American woman engineer, after winning a court case
that allowed her to desegregate Hampton High School to attend night classes. When
asked in the film by a white supervisor if she would still want to be an
engineer if she were a white man, she says that if she were “I would already be an engineer!” She also gives a
terrific
speech to the judge in her desegregation case about the significance and importance
being a “first”.

“Hidden Figures” portrays and does not downplay the blatant
and overt racism and sexism that existed in that period, legally in the Jim
Crow South where the film takes place at the NASA Langley facility in Hampton,
VA, in 1961, after Brown vs.
Board of Education but before the Civil Rights Act
of 1964. There are separate drinking fountains, and a separate coffee pot
for Ms. Johnson, and as graphically depicted in the film, a half-mile run for
her to go to the only “colored women’s” rest room to relieve herself! The laws
in the South came down, but racism – and sexism – there and in the rest of the
country are hardly things of the past.

But this is not a movie-review blog; it is about medicine
and public health and social justice. The social justice aspect should be
obvious, but let me start the discussion of health and medicine with science.
Clearly, science was at the forefront of NASA’s mission, and the film depicts
how the need for “best and the brightest” overcame even the structural racism
of the American South for these women. On a larger scale, though, the idea that
science was the future, that knowledge and education and learning and discovery
were critical to America and the world, are also implicit, scarcely discussed
in the film (save for a few inspirational speeches, such as President John Kennedy’s).
In 1957 Sputnik, the first satellite, was launched by the Soviet Union, in
April 1961 cosmonaut Yuri Gagarin orbited the earth and a month later Alan
Shepard was the first American to do suborbital flight. Glenn’s 1962 orbital
flight was only 7 years before the
Apollo 11 landed on the moon!

I was alive then, a fairly young child for Sputnik, older
for Gagarin and Shepard and Glenn, and just graduated from college for Neil
Armstrong’s “a small step for a man, a giant leap for mankind” speech. I was a
part of (maybe at the time I thought “victim of”) President Kennedy’s physical
fitness program, doing push-ups and sit-ups and chin-ups so we could “beat the
Russians”. I was also a student, learning and excited by science. I was
impressed by the space program, but not as dedicated a devotee as many others.
Perhaps this was because I was not enough
of a science geek, but perhaps it was also in part because it seemed natural,
the advancement of knowledge and science was natural, progress was natural. Maybe I was less awestruck than older people
in the same way that more recent generations have been less impressed by the
technology of computers and cell phones. But we all (I thought) believed that
science, and learning, and advancement were what the future was about. We had
come through “the war” (WWII), and Americans had jobs, and their children were
going to school, and while there were still fights to be waged for racial and
gender and economic justice, the outcome was, we knew, unquestionable progress.

But
maybe not any more. While we built the Interstate Highway system in the 1950s,
while we were able to go from suborbital flight to a man on the moon in 8 years
in the ‘60s, now we are in an era where many Americans – including many of our
leaders – deny the incontrovertible facts of man-made global warming and climate
change. An era in which science and scientists and not to be trusted, where,
when facts challenge our beliefs, we make up “alternate facts”, where education
and knowledge, rather than things to be sought after and admired are seen as “elitist”,
where the only persistent “good” is the enrichment of the already richest,
whatever the cost to the rest of us and to the planet. On April 23, 2011 (“Cabaret"
and "Inherit the Wind": Will we again reap what is being sowed?)
I wrote of how the play “Inherit the Wind”, written in the late 1950s, was
meant as an allegory for McCarthyism, since the “ignorance” that denied
evolution in 1920 Tennessee was no longer an issue; evolution was fact. And yet 60 years later it was still being questioned. We see the same, today, for all
aspects of science and knowledge; this is a real
test given by a “Christian” school!

But what about medicine and health? Is that not still the New
Frontier? We may have abandoned even the shuttle program with manned
spaceflight, and the launches from Cape Canaveral may be all private satellites
out to make a profit (or spy on us), but isn’t NIH our new NASA? Didn’t
President Obama promise a campaign to defeat cancer in the same way President
Kennedy declared our intention to get to the moon? Well, maybe. NIH’s budget is
not only stagnant, but its funding overwhelmingly goes to very basic research
and to find “bullets” to kill cancer, as if it were a disease rather than scores of diseases, almost all different. But
there is far, far less funding to prevent
cancer, not only to find the causes of these diseases, but to even
eliminate the causes when we know them. Where is the funding for public health?
Sure, there are some victories. Smoking, the major cause of death for decades (and,
although it is a cause of many cancers, more of the deaths it causes is from
increased heart disease and chronic lung disease than cancer), is down, but the
fight against it has been a long and hard one and is not over. Other
environmental causes of cancer such as air, water, and soil pollution are
minimally addressed, because, like smoking bans, they might decrease the profits
for some businesses and the wealth of the wealthiest.

“Hidden Figures” has
some brave acts by its white characters. John Glenn (Glen Powell) refuses to
fly unless Katherine Johnson rechecks the calculations (and thus she gets her
job back). Al Harrison (Kevin Costner), the NASA chief, takes a crowbar to the “Colored
Women’s Restroom” sign when he discovers that it is traveling to far-off segregated
restrooms that is taking Ms. Johnson away from her job. Yes, these can be seen
as self-serving (helping them to get their
jobs done) but they are also, in the context, heroic. I was recently sent
copies of archives of mimeographed newsletters from civil rights groups based
in southern Brooklyn, where I grew up; one of them contains an article from
1965 about young African-American women being denied membership in a “cabana
club” (in the NORTH! In Brooklyn, NY! In 1965!), until the singer Julius LaRosa shows up asks the folks
picketing outside why they are there, says “I don’t perform in segregated places”,
and intervenes.

John Kennedy said we should go into space not because it was
easy but because it was hard. Maybe we shouldn’t do things just because they
are hard, but we need to not deny what we don’t completely understand just
because it is easy. We need science and we need progress and we need public
health. People may not know everything themselves that environmental scientists
and scholars and mathematicians and physicists and doctors and public health
workers know, but they should be proud of those who do, and encourage and
support them. We need more girls and minorities to enter the STEM fields, as in
programs
such as that in NYC documented in the February 17 New York Times. We need more
Katherine Johnsons, and Dorothy Vaughans, and Mary Jacksons, and the love and
respect for learning and truth that they stood for.

Thursday, February 9, 2017

“There is,” in a phrase rightly or wrongly attributed to P.T.
Barnum, “a sucker born every minute.” To Barnum, and to countless others before
and since, this was a business opportunity. They can get rich off us because we
want stuff to be true even when every input from our senses should show us that
it isn’t; we want magical, easy cures and money-making schemes, even when we
know that they only work for the scheme’s designers, not the suckers who take
the bait. Betsy DeVos, the recently approved Secretary of Education, who knows nothing
about education and devalues public education (I could go on, but that’s
another story…) is the beneficiary of such desires. She is in the position that
she is in because of her great wealth which has bought her great influence, and
that great wealth, at least the portion from her husband’s side, derives from
the Ponzi scheme known as Amway. It is clear that Amway was in fact the path to
wealth that it was claimed to be, for the DeVoses anyway.

The persistent and widespread greed of people despite
evidence that the odds are stacked way against them is testimony to either
optimism or stupidity, or some of both. It is one of the oldest memes in
literature, from the alchemists who would turn lead into gold (or
Rumpelstiltskin who would weave it) to Faust who would sell his soul to the
devil (and maybe so did guitarist
Robert Johnson) to Ralph
Kramden (and his cartoon successor Fred Flintstone) and George “Kingfish”
Stevens, doubly oppressed and vulnerable, being poor and black. And the outcome is always the same, the little guy gets
screwed.

We could go on and on with this theme. The temptation to tie
it to the election and reign of Donald Trump is enormous; people want something to be true (that they’ll
get good jobs back, that their streets will be safe, that they can have all the
health care they want and need without paying for it when they don’t need it,
whatever) and Trump promised it all, and of course he is not and will not
deliver, but many still love him. If you want a good article about this, try
Matt Taibbi in Rolling Stone, “The
end of facts in the Trump era”. But, after all, this blog is about public health
and medicine, and there is no shortage of examples in those fields. After all,
con men and grifters, whether low level hucksters, Amway merchants, or Wall
Street bankers are all regularly called “snake oil salesmen”, and
what was snake oil but a promise of better health? And the liniment sold by
these folks might have worked a bit since it had red pepper, a bit like current
capsaicin. When they were convicted it was because their oil did not come from
snakes, not because it was a fraudulent cure.

You’d think that people would wonder why, if there is a
miracle easy (and sometimes even relatively cheap) cure for all their ills that
everyone else hasn’t benefited from it. Ah, but that is part of the attraction –
being in the know about something everyone else isn’t. Is that not the way that
inside traders work? Isn’t that how they fix sporting events, how your
brother-in-law knows that this 100-1 shot will come in at Santa Anita? Is that
not how Arnold
Rothstein got rich? So, sure, it’s done in health. Watch daytime television
sometime. It is mostly about medicine, from Dr. Oz (a font of misinformation),
to an electric scooter you can get FREE (or at no cost to you, other than as a
taxpayer paying into Medicare), or a miracle drug that will allow you to have
even better relief from your arthritis or asthma or will keep your blood from
clotting even better than warfarin, at only 1000 times the price, and at great
potential risk to your immune system.

The hucksters present not only misinformation about individual
medical care, but also public health. The most obvious, and likely most
serious, current issue is that of vaccines. Despite there being no evidence
linking vaccines to autism, and strong evidence showing there is no link, the
myth persists. The price will likely be serious outbreaks of vaccine-preventable
diseases, especially measles, as discussed by Peter J. Hoetz in his NY Times Op-Ed “How
the anti-vaxxers are winning”, February 7, 2017. Water fluoridation suffers
from similar myths. Public health may be even more susceptible to such hype
than medical care, since so many of its benefits are things (like measles, or
tooth decay) that don’t happen,
rather than those that do. We rarely wake up saying “Gee, I’m glad I don’t have
cholera today because we have clean water”; indeed, we mostly worry about water
quality when something specifically bad is happening, like lead poisoning in
Flint. People are susceptible to liars and charlatans who tell them things that
they want to believe, as well as things that seem to make sense, but as I tell
students, something that seems to make sense is called a research question; only when the study is done
will we know if it is true.

But it is not only the more obvious (to the discerning,
anyway) scams. Mainstream medicine does it often. Every new discovery, every
potential ameliorant (if not cure) is trumpeted by both the companies that
manufacture it and, at an earlier stage, the university for which they work. Of
course, most of these discoveries are scarcely the magic breakthroughs that
they are initially claimed to be. That is the nature of science; things are
learned and knowledge grows incrementally. But a new discovery by a scientist at your
university is worth a lot of publicity! Maybe it is a cure for Alzheimers!
Or at least a step in that direction! Certainly worth millions of dollars more
in NIH funding! There is nothing wrong in incremental discoveries; the problem
is when they are hyped as the Holy Grail. Indeed, on July 16, 2010, I wrote
about Rosiglitazone
and the "Holy Grail", and how disappointed diabetes advocates
were that Avandia® was being taken off the market just because it caused heart
disease, because it did lower blood
sugar! (A diabetes advocate noted that lowering blood sugar was the “Holy Grail”.)
This story is a terrific example of the peskiness caused by the human body
being an integral organism; something that is very good for one condition may
still cause big problems. And so, maybe we should wait before we hype it too
much. On the other hand, what an opportunity
we have to get big publicity before that happens…

A recent example involves using low-dose CT screening for
lung cancer. The
US Preventive Services Task Force recommends it (as a “B” recommendation) for
men 55-80 years old with a history of smoking. This “B” recommendation is
worth a lot to the CT manufacturers and radiologists who read them, since the
ACA requires insurers to cover USPSTF “A” and “B” recommendations. But a big
Veterans Administration study just published in JAMAshows that it is not quite as good as previously thought. “Of the 2106 patients screened, 1257 (59.7%)
had nodules; 1184 of these patients (56.2%) required tracking, 42 (2.0%)
required further evaluation but the findings were not cancer, and 31 (1.5%) had
lung cancer.” Does this mean that it is a bad idea to get screened? Not
necessarily; if I had a patient with a significant smoking history, I would
discuss the risks inherent in getting this procedure but prepare them for the
probability that even a positive test would likely not mean they had cancer,
and that they might have to undergo more procedures with some risk to find out.
The point is not that this is a bad idea, but it is not some amazing
breakthrough, as touted.

Just because you want to get rich quick, or avoid needle
sticks, or find the magic cure for your arthritis or cancer that has been
denied you, and someone is selling something that claims to do it, doesn’t make
it true. If you think so, I’ve got a couple of bridges to sell you.